Treatments

How is Testicular Cancer treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society’s Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience. The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask him or her questions about your treatment options.

Making treatment decisions

In recent years, a lot of progress has been made in treating testicular cancer. Surgical methods have been refined, and doctors know more about the best ways to use chemotherapy and radiation to treat different types of testicular cancer. After the cancer is diagnosed and staged, your cancer care team will discuss treatment options with you. Depending on the type and stage of the cancer and other factors, treatment options for testicular cancer can include: Surgery Radiation therapy Chemotherapy (chemo).

High-dose chemotherapy and stem cell transplant. In some cases, more than one of type of treatment might be used.

Medical team

You may have different types of doctors on your treatment team, depending on the stage of your cancer and your treatment options. These doctors may include:

A urologist: a surgeon who specializes in treating diseases of the urinary system and male reproductive system

A radiation oncologist: a doctor who treats cancer with radiation therapy

A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy

Many other specialists might be involved in your care as well, including physician assistants, nurse practitioners, nurses, physical therapists, social workers, and other health professionals. See Health Professionals Associated With Cancer Care for more on this.

It’s important to discuss all of your treatment options as well as their possible side effects with your doctors to help make the decision that best fits your needs. (See the section “What should you ask your doctor about testicular cancer?” for some questions to ask.)

When time permits, getting a second opinion is often a good idea. It can give you more information and help you feel good about the treatment plan you choose. Where you are treated is important. There is no substitute for experience. You have the best chance for a good outcome if you go to a hospital that treats many testicular cancer patients.

Therapies

In most cases, surgery to remove the affected testicle is the first line of treatment. It is called an orchiectomy.

Depending on the type of germ cell tumor, serum marker analysis and scan results, your health care team will identify the stage of the cancer and decide if other type of therapies are required at this time. Options include chemotherapy, radiation therapy or surgery.

If scan and blood test results are normal, you may need other treatments. However you will be required to regularly and frequently undergo blood tests, x-rays and other types of scans for many years to come. Later on, should results become abnormal and indicate a recurrence of the cancer, you will need to be treated (probably with chemotherapy).

Should you have a seminoma, even if scan results are normal, you may need abdominal radiation therapy. If you have a non-seminoma, you may need surgery for abdominal lymphatic nodes, a procedure called a retroperitoneal lymph node dissection.

Your physician may have other reasons for suggesting a treatment plan other than these general therapeutic options. Do not hesitate to ask him or her questions about the various available options.

Some patients use medicinal plants, high doses of vitamins or strict diets. Before you consider such things, it is important that you discuss this with a member of your healthcare team. Some of these products could be harmful to your therapy.

Our information is derived from opinions expressed by physicians and nursing personnel who sit on the data base editorial committee of the American Cancer Society. Such opinions are based on the interpretation of studies published in medical journals and on their own professional experiences. The information on therapeutic options presented herein does not represent the official position of the American Cancer Society and does not aim to provide medical advice in lieu of the expertise or the judgement of your oncology medical team. The objective of this information is to help you and your family make informed decisions in conjunction with your physician.

Effects on fertility

Cancer fighting treatments can require surgery, radiation therapy and/or chemotherapy. These are used to destroy cancer cells while avoiding, as much as possible, to destroy healthy cells. Such treatments can alter the reproduction function and lead to a temporary or permanent loss of fertility.

The risk of becoming sterile depends on the treatment, its duration and the doses used. Indeed, it varies a great deal from one patient to another. The risk depends on how well the stem cells that produce sperm tolerate therapies. Regular sperm monitoring tests are conducted over a long period of time to verify sperm production evolution.

The next few sections describe the different types of treatments used for testicular cancers. This is followed by a discussion of the most common treatment options, based on the type and extent of the disease.

Some patients use medicinal plants, high doses of vitamins or strict diets. Before you consider such things, it is important that you discuss this with a member of your healthcare team. Some of these products could be harmful to your therapy.

Orchiectomy

The diagnosis and initial treatment for testicular cancer is surgery to remove the affected testicle (orchiectomy). While it may be possible, in some cases, to remove testicular cancer tumors from a testis while leaving the testis functional, this is almost never done, as the affected testicle usually contains pre-cancerous cells spread throughout the entire testicle. Thus removing the tumor alone without additional treatment greatly increases the risk that another cancer will form in that testicle.

Since one testicle is usually adequate to maintain fertility, hormone production, and other male functions, the affected testicle is almost always removed completely in a procedure called radical orchiectomy. (The testicle is almost never removed through the scrotum; an incision is made beneath the belt line in the inguinal area.)

What are treatment choices after you’ve removed the testicle?

Depending on the type of cancer, stage of cancer, and serum tumor marker levels, the choices include chemotherapy, radiotherapy, surgery or surveillance (treatment only if the cancer recurs).

Chemotherapy

Chemotherapy is drug treatment to kill cancer cells. For testis cancer, treatment is usually given intravenously with a combination of two or three different drugs. The drugs are given for 5 days in a row and then once a week every 21 days. This is called a cycle of chemotherapy. Three or four “cycles may be given. For testis cancer, chemotherapy is used mainly for more advanced cases of both non-seminoma and seminoma.

Although chemotherapy is intended to kill cancer cells, some normal cells and organs will also be affected as “innocent bystanders.” The damage to normal cells presents as “side ¬effects” of the chemotherapy. Some side ¬effects are seen and felt soon after starting the chemotherapy treatment. Rarely, some side ¬effects only become a problem years after the treatment.

What are the side effects?

Nausea and vomiting : there are very effective drugs to help prevent this that you will be given.

Hair loss: growth will return after a couple of months after the chemotherapy has been completed.

Temporary stoppage of sperm production (by the other “healthy” testicle – assuming the one with the cancer has already been removed).

Low blood counts including red blood cells, white blood cells and platelets. Red blood cells contain “hemoglobin,” which carry oxygen to the different organs. A low red blood cell count or low hemoglobin is called anemia that may cause tiredness, shortness of breath, general illness. White blood cells help fight infections. A very low white blood cell count causes a person not be able to fight infections. . Throat, lung and urine infections are the most common. Platelets help the blood to clot and stop bleeding if there is a cut or injury. A very low platelet count makes the person to bleed and bruise much more easily but this is not common. . These problems usually resolve after the chemotherapy has been completed. Occasionally, your doctors may have to give you a medication to help increase the white blood cells, give you antibiotics or give you a transfusion of blood or platelets.

Some side effects occur only with particular drugs. For example, lung and skin problems may occur with a drug called Bleomycin; kidney, hearing, nerve function and circulation problems may occur with Cisplatin; Some of these problems are mild and temporary. Others may be more serious and longer lasting.

Radiotherapy

Radiotherapy (or radiation therapy) is a treatment delivered from a machine with a beam aimed at the tumour. For testis cancer, radiotherapy is most often used to treat the abdominal lymph nodes in patients with seminoma after the testis containing the cancer has already been removed.

The radiation causes damage to the cells in the path of the beam. Both cancer cells as well as normal cells are affected and so side effects may occur.

What are the side effects?

There may be skin changes similar to a sunburn.

Diarrhea, general tiredness and stomach upset may occur but are relatively uncommon.

Low blood counts very rarely occur.

The remaining healthy testicle is shielded or protected from the radiation beam with a lead apron during treatment, so that normal functions of the testis, (i.e. making sperms and male hormones) can continue.

RPLND

(RETROPERITONEAL LYMPH NODE DISSECTION)

Some patients will need removal of the lymph nodes of the abdomen (the “retroperitoneal area”). This may be recommended after removal of the testicle or after chemotherapy or radiation therapy.

The RPLND surgery is a major operation on the abdominal area performed under anesthesia, lasting several hours and requiring a hospital stay of several days. The lymph gland tissues (often enlarged and grown into one solid mass) near the kidneys, main artery of the body (the “aorta”) and the main vein (“the vena cava”) are removed.

What are the side effects?

The side effects include problems that may occur during anesthesia, especially with the lungs.

Infection in the wound is sometimes a problem.

The main arteries and veins may be injured, resulting in major bleeding.

Several abdominal organs may by accidentally damaged, including the intestines, the kidneys and their drainage tubes (the “ureters”), the spleen and pancreas.

Some delicate nerves which control the discharge of semen fluid during sexual activities run very close to the lymph glands being removed. Most of the time, your surgeon will try to save those nerves to avoid problems with semen discharge during sex. Occasionally, there will be problems with semen discharge during intercourse afterward this surgery, but erections will not be affected.

Treatment Follow-Up

Long term regular follow-ups are important in the treatment of testicular cancer. You have to undergo various tests that will inform your healthcare team about your general health and they can adjust your treatments accordingly.

These tests can include :

A physical check-up

Your physician will give you a complete physical that will include…

palpation of the other testis,

palpation of the neck, underarms and stomach to see if your lymphatic nodes are swollen.

Blood work-up

To verify your general state of health and your tumoral markers.

Various imaging tests

lung x-ray,

CAT scan (computerized axial tomography): a test that is similar to an x-ray, but that provides three dimensional images of your abdomen.

Post-treatment follow-up

Men who have had cancer in one testicle are at a very low risk of developing cancer in the other. Should this occur, it is usually a new cancer and not the original tumour that has spread. Risk of testicular cancer recurrence is highest during the first two years.

Testicular cancer acts differently in each man, and that is why a standard follow-up regimen is not always appropriate. Patients should talk about a follow-up program that meets their personal situation with their physician. The surgeon, cancer specialist (oncologist) and the family doctor often share this responsibility.

At the end of your treatments, you must inform your doctor of any new symptoms and other persistent symptoms. Do not wait for your next appointment to do so. Men who have had testicular cancer are at very low risk of developing cancer in the other testicle. If this does happen, it is usually a new cancer and not the original tumour that has spread.

The risk of recurrence of testicular cancer is highest during the first two years.

Follow-up planning

Follow-ups vary after treatment for testicular cancer. Medical consultations are usually set up as follows:

Every 2 or 3 months for the first 2 years,

Every 6 to 12 months for 5 years or more.

Interventions

A follow-up appointment usually consists of the following:

Medical history

The physician can ask questions about:

The side effects of the treatment,

Your ability to adapt to a different body image,

Concerns about fertility,

Concerns about sexual function.

Physical check-upThe doctor may do a complete physical, including:

Examining the remaining testicle,

Palpation of the pelvic and groin areas to see if there is any swelling of the lymphatic nodes.

Lab tests and imagingTests may be prescribed as follow-up, or if the physician suspects a recurrence of the cancer. (relapse)

Imaging : Lung x-ray; CAT scan (Computerized axial tomography),

Blood work-up.

Regular and long term follow-ups are important in the treatment of testicular cancer.

Afterwards...

I’m told my treatment is finished. Others around me are so pleased, but I just can’t seem to feel the same way. Is it normal for me not to be totally thrilled?

Absolutely! The others are happy and reassured knowing that you’ve been saved from that frightful disease. But you have just gone through a marathon that asked so much of you both physically and psychologically. Fatigue often sets in once the pressure has gone down and that ‘danger’ is no longer imminent. This is on top of the fatigue associated with your therapy. For many people happiness isnot necessarily the one emotion they have. You have gone through an experience that has impacted you and that might have been associated with fears and other unpleasant feelings. Patients are often ambivalent at the end of their therapy; they are concerned yet happy that it is over and done with.

If you are worried about a relapse or about your health in general, remember that the medical team will ensure regular follow-ups with you. Try to think about the ‘now’. Redefine your priorities and move forward with projects that are important to you and do so at your own pace, this will make you feel alive. Slowly but surely, as you get involved in both old and new projects, and as you get positive scan results, the anxiety associated with a fear of recurrence should fade. You may be more prone to feelings of anxiety at certain periods of the year, for example on the anniversary of your diagnosis or when you are waiting for the scan results, etc. At those moments, try to do activities that calm you down, or do something to help you think about something else. This experience is part of you now, you can erase it, but there are ways of decreasing the anxiety and the fear and it is up to you to explore and discover what is appropriate for you personally.

This is often the time when patients find the need to seek professional help. It is not abnormal to have contradictory feelings or anxiety. In fact, it can be difficult to pick up where you left off (studies, work, romance, etc.) as if nothing has changed or to contain that fear you have of relapsing. Some men find that they have changed so much that they are no longer comfortable in their former role. Do not hesitate to use this transitional period to make changes in your life. Cancer is an impactful experience that may make you think about yourself and your future. However, your first challenge should be to take the time to recharge your batteries and get over your fatigue. If this transition to a time when ‘you are going back to a so-called normal life’ becomes a source of psychological distress for you, do not hesitate to consult a psychologist.

In short, testicular cancer is an experience that is deeply overwhelming and that has repercussions on all facets of a person’s life. Keep in mind that for most men, this is a transitional period of their life as a young adult. It will require patience, time and multiple adjustments. What can you do to help yourself? Don’t stay alone, consult if you feel the need to do so, use the resources made available to you and keep the channels of communication open with the people closest to you. Effectively implementing the recommendations of your medical team will enhance your chances of improving your health and wellbeing. This is how you should look after yourself through your therapeutic pathway. Remember that there is no good way, there is no bad way of reacting to disease. Respect your own pace and your own needs, in other words, trust in yourself!

If you feel like sharing your experience or simply want to talk with other guys who have gone through this, contact us – that is also why we are here.

Patients often feel ambivalent once their therapy is over; feelings range from being worried to being happy that it is all over.

Source : Text written by a psychologist and a social worker from the supraregional multidisciplinary uro-oncology team at the CHUM, 2014